Declaration of interest: Papers and studies for which John Baker is a co-author have been included in the NICE draft evidence review that is the focus of this blog.
The Francis Inquiry (2013) focused the attention of the general public onto poor quality nursing care. As a direct result of this inquiry, NICE was asked to review the evidence base for safe nurse staffing levels in nine care settings in England. Two of these reviews focused on mental health, with reviews proposed for acute inpatient and community care. This work was halted in June 2015 by NHS England, and it was thought that the majority of this work would not be completed and published.
Inpatient (acute) mental health care has been under considerable strain, with increasing numbers of service users being detained under the Mental Health Act, suggestions of rising acuity (i.e. prioritising patient care based on the presenting symptoms/conditions during triage), all delivered in services with fewer beds.
There is a widely held perception that in recent years that cost continues to outweigh safety, with a reduction in, and the downgrading of qualified mental health nursing staff. Qualified nursing staff to patients ratios in acute inpatient wards are often less than the 1:8 recommended in other ward settings. There are numerous reports published over the last 20 years from service users about poor quality (Mind, 2013), unsafe and inadequate care (Mind, 2014) in acute inpatient wards.
To date, there has been limited guidance about the optimum nursing skill mix to ensure safe and effective acute inpatient care, and it did seem that the reviews conducted by NICE would never be made publicly available.
— Shaun Lintern (@ShaunLintern) January 20, 2016
Aims of the NICE safe staffing review
The review conducted by NICE had seven main questions:
- What service user and other outcomes are associated with safe staffing for nursing inpatient mental health settings?
- What service user factors affect nursing staff requirements in inpatient mental health settings?
- What environmental factors affect nursing staff requirements in inpatient mental health settings?
- What staffing factors affect nursing staff requirements in inpatient mental health settings?
- What organisational factors affect nursing staff requirements in inpatient mental health settings?
- What core nursing activities should be considered when determining safe staffing requirements for nursing in inpatient mental health settings?
- What approaches for identifying safe staffing for nursing and/or skill mix, including toolkits, are effective in inpatient mental health settings and how frequently should they be used?
A broad search of the literature was undertaken using the standard methodology for NICE guidelines. A range of databases were searched including BNI, CENTRAL, CINAHL, DARE, EMBASE, Cochrane, and Medline. Literature published from 1998 onwards was included.
The review included all inpatient mental health settings, across a range of countries. Although papers needed to focus on staffing and outcomes and/or other factors, patient satisfaction was excluded unless it related to staffing.
The review focused on 4 main outcomes:
- Serious incidents, and coercive interventions (conflict and containment outcomes)
- The delivery of nursing care
- ‘Others’: including access to services and assessment
- Reported feedback from service users and carers
- 29 papers were included, the majority of which were observational studies:
- 25 studies were classed as cross-sectional,
- 10 studies (rated of low quality) described associations.
- Literature was included from a range of clinical settings and a number of countries including England, Scotland, Norway, Australia, USA, New Zealand, Japan and Switzerland.
- The majority of the papers came from studies associated with Professor Len Bowers and the CITY 128 project (Bowers et al, 2006).
- There was widespread variation in reporting staffing levels and measuring outcomes.
- Four studies linked staffing levels and conflict; concluding that higher staffing levels were associated with increased rates of assault.
- Three studies linked staffing and containment interventions, which again indicated that higher staffing levels were linked with more seclusion and restraint.
- Five studies explored staffing and ward outcomes, and it appeared that fewer staff were linked with greater emotional exhaustion.
- 16 papers linked staffing and containment and conflict outcomes, the majority of which were conducted by Bowers. Results suggested that male and more qualified staff were present prior to conflicts occurring, and higher levels of unqualified and temporary staff were associated with high levels of conflict and containment.
- Only two studies provided data on what nurses do.
- No studies provided sufficient detail to identify safe staffing levels.
The guidelines concluded that there was:
- No evidence that specifically describes how minimum staffing levels or ratios may support safer nursing in inpatient mental health settings.
- A lack of high quality intervention studies demonstrating the direction of the relationship between nurse staffing and key outcomes.
- No evidence on service user factors which may need to be taken into account when setting nurse staffing establishments.
- Very little evidence on environmental and organisational factors which may need to be taken into account when setting nurse staffing establishments.
- No robust evidence to support the use of particular approaches or toolkits for identifying safe staffing requirements for nursing and/or skill mix.
- No evidence from economic evaluations regarding the cost effectiveness of different nurse staffing models or approaches.
The findings of NICE are not surprising; there is a dearth of research into acute inpatient wards, how they should be staffed, and more importantly the key outcomes that they should be producing.
The majority of literature included in these guidelines focused on coercive interventions, but it seems clear that the presence of qualified nursing staff contribute to reduced frequency of the need for these interventions. However, these are probably not the outcomes that service users would prioritise and it remains clear that acute inpatient wards do not offer safe environments and therapeutic interventions that meaningfully contributed towards an individual’s recovery.
It is clear that when wards are disturbed, additional nursing and support staff are deployed to bolster the numbers. These staff are often unqualified nursing assistants provided through bank or agency systems. This is often costly and these additional staff are more likely to use coercive means to manage the ward environment. They are also less likely to know the service users on the ward. Additional investment in qualified nursing staff may enable staffing levels to move from the current minimum unsafe level to levels which enable therapeutic environments to occur. This could result in better quality and safer care, improved outcomes, and reduce costs associated with the use of bank and agency staff.
Whilst governments are always reluctant to mandate numbers of staff because of the economic and political consequences, it is important that evidence which can encourage informed debates is not suppressed. There is also a debate to be had within the profession and wider service about the mix of staff required to provide the optimum care within acute inpatient wards. However, the work delivered in place of the Mental Health Staffing Framework is not supported by this review as an evidence-based method. There is no indication that the Mental Health Taskforce has included #SafeStaffing within their remit, and the working groups which were to be delivered to conduct additional work have not yet been convened.
Indeed the nursing profession has been slow to develop research of sufficient quality to ensure #SafeStaffing in mental health settings. This has resulted in acute inpatient wards with fewer nurses, and those who remain are often on lower grades, resulting in an unsafe and ineffective minimum number of staff.
The unearthing of this review should galvanise the mental health nursing community to answer this vital question: how many nurses does it take to provide a safe and therapeutic environment on an acute mental health inpatient ward?
NICE (2016) Safe Staffing for Nursing in Inpatient Mental Health Settings (PDF). National Institute for Health and Care Excellence, Draft evidence review, 2016.
Royal College of Nursing. (2014) Frontline First: Turning back the clock? RCN report on mental health services in the UK. November 2014.
Francis R. (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry: executive summary. Jan 2013.
Bowers L. et al (2006) The City 128 Study of Observation and Outcomes on Acute Psychiatric Wards: report to the NHS SDO Programme (PDF). City University Department of Mental Health and Learning Disability, Dec 2006.
MIND (2013) Huge rise in complaints about mental health care made to NHS, MIND, London.
MIND (2014) Parliamentary briefing from Mind (PDF), MIND, London.
NHS England (2015) Mental Health Staffing Framework. NHS England, London.